Introducing the new Mariner 2 Walnut

10 May 2012

It’s been just over a month that Micah True’s body was found in the rugged wilderness area of southwestern New Mexico. The legendary ultrarunner and memorable “Caballo Blanco” centerpiece of Born to Run had gone missing after a rather routine 12-mile trail run. An autopsy report released Tuesday by the Office of the Medical Investigator in New Mexico showed that the 58-year-old runner had cardiomyopathy, a disease that results in the heart becoming enlarged.

According to the Associated Press, “While medical examiners couldn’t point to the cause of the heart disease, they said True’s left ventricle, the chamber of the heart that pumps oxygenated blood to the rest of the body, had become thick and was dilated. That can result in an irregular heartbeat during exertion.”

Ultra runners are still puzzled by True’s sudden death. They all thought he was exceptionally fit and healthy. The Associated Press quoted two of Caballo’s friends, both of whom participated in the search in the Gila wilderness.

Scott Jurek: “It doesn’t fit with him going on a two-hour run. It wasn’t exceptionally hot. By a lot of ultra-marathoners’ standards, it was pretty simple. I doubt he was running that hard. I think it was just a matter of timing.”

Chris McDougall: “This is a guy who could set out with a little bag of ground corn, a bottle of water in his hand and be gone all day. The day before he died, he did a six-hour run.”

The autopsy report concluded that “the manner of death is natural.” But that statement, by itself, is less conclusive than it seems. Could True’s death have been prevented? Why then, and why during a relatively easy run? The NRC asked one of our health advisors and frequent contributors, Dr. Steve Gangemi, aka the Sock Doc, to look over the autopsy report and offer his opinion. — Bill Katovsky

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Nothing “Natural” About Dying from an Enlarged Heart

by Dr. Steve Gangemi, aka the Sock Doc

It’s interesting to read a report, in this case an autopsy report, which reads that the individual died of a disease that was “natural”when that person was only 58 years old and supposedly in excellent health. The medical examiner performing the autopsy has deemed True’s death a result of unclassified cardiomyopathy which resulted in a cardiac dysrhythmia during exertion.

Basically this means that he died because his heart muscle was deteriorating slowly over time and eventually this created the electrical activity of his heart to beat abnormally most likely leading to inefficient pumping of the heart and finally cardiac arrest. Normal? Definitely not. Common? Perhaps very much so.

The examiner further states, “The manner of death is natural.” Natural? I’d like to think not–a heart doesn’t “naturally” fail in such a manner, especially at 58 years of age. Though the most common reason for cardiomyopathies is ischemia (lack of oxygen supply to the heart), the medical examiner notes that there was no evidence of ischemia or inflammation of the heart. It’s all a bit strange.

So since there was apparently no ischemia or other cause for True’s heart disease, this could very well leave one to speculate that his condition, and death, was one which resulted from hypertrophic cardiomyopathy. Hypertrophic cardiomyopathy (HCM) is a thickening of the heart muscle and the most common leading cause of sudden cardiac arrest in athletes. Those with HCM often have a severe thickening of the left ventricle of the heart, and True’s autopsy does clearly state this. This condition, known as left ventricular hypertrophy (LVH) can eventually result in cardiomegaly –an enlarged, inefficient heart.

The medical examiner does note in his review of the cardiovascular system that True’s “heart is enlarged” and further notes “mild to moderate arteriosclerosis”, though he makes no relationship of either condition to his LVH and further back to his HCM — his “cause of death.”

Ultimately True died in the same matter many fit but unhealthy athletes have died in the past, and unfortunately many more will succumb to the same fate in the future. In 2007, during the Olympic marathon trials, 28-year old long distance athlete Ryan Shay collapsed and died from a heart attack. He, like True, also had cardiac hypertrophy, and subsequently cardiomegaly. And like Caballo Blanco, his final autopsy notes that he too died of
“natural causes.

I can assure you one thing – dying from a heart attack due to prolonged, chronic structural changes in your heart is far from natural. A thickening and scarring of cardiac tissue is the result of the body’s inability to keep up with prolonged and excessive stress demands – essentially it’s in constant repair mode, and losing. Shay had this process occurring in his heart (fibrosis) and True in his arteries (arteriosclerosis). These “osis” conditions are due to free radical damage, inflammation (even temporary, but frequent), and hormonal and metabolic problems that occur from training too hard, lack of rest, improper diet, and other lifestyle factors.

In the upcoming Part V of the Sock Doc Training Principles, I will go into further detail how and why highly conditioned athletes are dying from chronic endurance training and steps you should be actively taking now so you too don’t all of a sudden die from a “natural cause” such as a heart attack, cardiac arrest, or any other disease or disorder in which your body can no longer keep up with the demands you place on it.

Richard is somewhat correct. If he did indeed die of some type of cardiac failure, caused by an underlying heart condition, then it was a natural death. Meaning, it was not a homicide, suicide, or accident, and therefore NATURAL. Maybe "Dr." Gangemi needs a little more training.

I understand the word; here it's a use of how people use it and think it's natural that someone can just die at a certain age and it's not "un-natural". Sure it's different in an autopsy report; but different when discussing it in regards to health.
I'm sorry you only saw the use of that word "incorrectly" rather than the facts & science leading up to it. I guess I'll go back to word-use training school.

Regardless, we could argue the point of natural causes all day. I am not going to argue. I am going to mourn the loss of a man with a heart bigger than his smile, who found his calling in life was to run like the wind, and in doing so help a small community of people, and in turn touch a larger community of runners fast and slow, young and old. The legend of Caballo Blanco is deftly and eloquently penned for us in the pages of "Born To Run", and although I have not met the man, you feel a kinship with someone like Caballo, perhaps that is why runners and non-runners alike grew so attached to the book character and the man in life. Those blessed enough to have met him, befriended him, laughed and ate and drank with him, will tell you that humanity lost a very positive being. May the White Horse run forever.

Yes I too saw that the medical examiner wrote that. He does say it doesn't fit because it is "usually asymmetric" so it doesn't fit the HCM diagnosis, but remember this isn't about a "diagnosis."
As I explained to another reader on another site it's much like if you have shin splints, plantar fasciitis, and back pain. The typical therapist or medical doc is going to diagnose each one and treat each one individually. That's how they compartmentalize problems and it does very little, usually. In what I like to refer to as systems health care you see the link between the diagnoses, and understand the process occurring as a whole.
Here, as I mention, you see that Micah had an enlarged heart - often from LVH. He had LVH - and that often goes with HCM. So I'm not saying he has HCM, but I am noting that's it's very curious that the medical examiner doesn't point to the connection. Maybe he had some reason for not doing so. I'm not a medical examiner and not a cardiologist and I'm definitely not trying to diagnose the death of True. Even if he died from another means and the report still said this about his heart, it's very noteworthy due to the common occurrence in athletes who are dying so suddenly.

@Jallen: why go into semantics to attack (even if mildly) someone else? It's very clear from Mr. Gangemi's post that he uses the word "natural" in a different way than the autopsy report. The point he is trying to bring across is pretty simple: Micah's death might be natural when looked at from a forensic perspective, but it's not when you look at it from a health-perspective!

Thanks for the insights, Dr. Gangemi.
It makes me sad, that a guy like Jallen picks on the use of one word. Finding some error is easy, but taking time and sharing your thoughts is much more difficult and important. A very tiny person he sure is.
So once again for the not so grateful: Thank you, more please!

Jack - that's more than uncalled for. Am I just a bone cracker to you? Should no medical doctor on this site (there's lots of them) share anything on musculoskeletal injuries or nutrition since they're not "schooled" in that, or are they okay with that since in your world they know everything?
How did I mislead you? Please share.

The facts and science leading up to it, and how it was used in the official autopsy report, does have an impact on the meaning of the word natural regardless of what context you use it in. By using the phrase "natural death" the medical examiner was not saying that BCH was natural in the sense that it is normal or non-pathogenic.
So yes Jan and Martin, I will pick on semantics and 1 word because it is at the center of Gangemi's whole article. I was merely pointing out that whatever pathological cardiac condition Caballo died of, it was, from a medical examiner's and cause of death view, natural. Neither the autopsy report nor the medical examiner that wrote it were trying to say that BCH was a natural, normal heart condition, even though reading this article may lead you to believe that.
Go ahead back to word training school. It wont help you become any better of a physician... err.... chiropractor.

Could you discuss the possibility of Chagas Disease being a factor? Drs. Google and Wikipedia list cardiomyopathy as one of the possible symptoms of Chagas. And it might be useful to consider the role that lack of routine, quality health care may have played in allowing True's problems to develop unaddressed. While we may respect or romanticize his austere running, the stories seem to indicate a guy who lived very frugally, under substandard physical conditions in rural Mexico, and very likely without routine access to modern health care. I don't think furniture moving for cash and the occasional trek guide gig would give you a great health care plan. Poor water, lack of good health care, exposure to extreme temperatures, all in the Chagas disease zone...Perhaps these factors may have helped bring down a man who otherwise had exemplary health habits. At very least, someone with some exposure to tropical diseases, or the long-term effects of poverty, might weigh in VPAon the autopsy, if only for perspective.

I had a friend who ran marathons in his 60's go in for a physical. The doctor found his heart was enlarged which indicated that he was either very fit or had a heart problem. After several tests they concluded that he was very fit. He is now in his 70's and placing in his age group in national bike races.
So what is the difference between a healthy enlarged heart of an athlete and a sick enlarged heart of an athlete?

First Thank you Steve for the courage to write this post and open discussion to what this may mean to any one like Micah who goes out for a weekend trail run.
Tom,
This is a question without an answer, as the "well" enlarged hearts are not having autopsies. There are 1000's of athletes around the world who's hearts would be termed "pathologic" by measurements/EKG but truly are "physiologic". Trust me as a US Air Force doc who had to jump through several hoops and tests as well as "expert opinion" to be cleared to be in the USAF. So the age group performer is an outlier when looked at in the lens of a regular patient. There are no perfect tests to predict who may have an event or arrhythmia.
Also this autopsy did not make any firm conclusion, other than speculation based on the fact the heart was thickened (as would be the case in most serious endurance athletes)
So bottom line...exercise for life in the comfortable and fun way of Micah and the Tarahumara. Dr. George Sheehan said 30 years ago "exercise may not add years to your life , but it adds life to your years." We know now that it adds years to your life too :)
Dr. Mark

Hello folks.
When i learned of Micahs passing but had not heard any details of the cause, apart from the fact that he was found to have died during a run, i recalled in the book Born to Run the mention of how he had mysterious blackouts from time to time. Has this been considered in relation to his death.Surely this is a sign that he had some sort of condition out of the ordinary that may not show in autopsy?
Just a thought.

To all Dr.'s
I am 31 and had heart surgery when I was 15, ASD (Atrial Septal Defect) or hole in the heart. I was given a clean bill of health before I was 20, continued to play baseball through college and been considered in very good shape while eating what most would call a "southern home cooking diet" I still have an enlarged left side of my heart and while I've always thought of myself as a Secretariat like athlete, since Micah True's falling I've been wondering more about my heart and what is becoming a documented failure of athlete's hearts. I am asking for any advice, thoughts, and anything I have not thought of.

Dan, you just do everything you can do to make sure you live as healthy a life as possible. Train smart, eat well, rest well, lower stress - all the things we talk about here and I do on the SockDoc site. You could also consider an updated EKG and/or stress test with echo.

As a doctor who teaches medicine, I often explain to medical students that medicine is filled with deception. I explain that the language of medicine can be used as a language of deception. To say that Micah True died of a "cardiomyopathy" is deceptive. Micah True had an enlarged heart, as is the case wiht many aerobic athletes. They reported "mild dilation" but mild dilation does not kill a person. The heart has an electical system just as a car has an electrical system. The heart itself is more analogous to the engine, but a very fine wire can be needed in certain places to make the engine run or make the heart run. Excessive exertion that strains the heart, hormonal changes associated with excessive exertion or even intake of supplements can lead to electrical instability and death. For example, I ran a marathon in Houston years ago. A 24 year old triathlete died in that marathon. He was running at a pace of about 5 minutes and 30 seconds per mile, until about 20 yards from the finish line. He dropped at that point. They found supplements in his apartment and those supplements contained vitamins and potassium. He took them before the race because his understanding of medicine and physiology was poor, as it the case with many in our society. That is why the supplement is so big. It was the potassium in the supplements that killed him. But potassium is a normal chemical in the body. Hence, if Micah True did what many runners do - i.e., take these supplements that seem benign and helpful but are in fact, dangerous- then there is no way an autopsy would find this. As a doctor, I have seen patients make such errors a number of times.
And I have seen plenty of errors made in autopies. Micah True did not have a cardiomyopathy. Pathologists come out with such nonsense all the time. Look up the autopsy on Jim Morrison of the Doors. The diagnosis on his death certificate is listed as heart failure.

Thanks for the informative comment Dr. Graham. I think the idea we are all trying to make here is that it's not about the "final diagnosis" but the processes that lead up to such - that's what is important.
Quick comment on the athlete with potassium as that's one question I get a lot of from my patients. Contrary to popular belief, cramping is not often from a potassium deficiency. Dehydration, glycogen depletion, and low calcium and/or sodium are much more of an issue with cramping than potassium. I'm not sure of the exact situation of the runner in the case Dr. Graham mentioned here (the supplements, if taken in high enough dose very well could have killed him), but hyperkalemia (high potassium) is often due to a kidney problem, significant adrenal gland stress, or even a result of other medications. Supplements alone most likely will not be the causative factor in most cases (of death anyway - but they a lot of people cause health problems from taking things they shouldn't), but perhaps the final one in a mix of many.

Thanks for your response.
As you know, excretion of potassium takes place in the distal tubule, primarily under the influence of aldosterone. Therefore, if the GFR goes down then delivery to the distal tubule goes down and hence ones ability to excrete potassium goes down. The runner who died did not drink during the race. Hence delivery to his distal tubule was likely compromised. Like many runners during that distance, he probably also has rhabdomyolysis which released potassium into his bloodstream. In other words, it became the sort of perfect storm. As you say, it is not common for such a perfect storm to arise, but it did in this case.
We should also emphasize that electrical instability in the heart is quite common in athletes, such as true. Atrial fibrillation, SVT, etc. is seen out of proportion to the general population.

I wonder if True ever had any syncopal events during exertion.
AN ESTIMATED 24% OF PEOPLE WHO EXPERIENCE CARDIAC SYNCOPE SUBSEQUENTLY DIE FROM SUDDEN CARDIAC DEATH. IN PEOPLE WITH CARDIO-VASCULAR DISEASE, DEATH RATES ARE REPORTED TO BE 30% IN THE FIRST YEAR, AND APPROACHING 50% IN FIVE YEARS. (Source: Pathogenesis and etiology of syncope Brian Olshansky, MD Christopher S Cadman, MD) Cardiac cause is more likely in men than in women.

Why were his legs resting in a stream? Sounds like he as trying to cool down and or rehydrate and perhaps the mild dehydration mentioned in report was more than mild. His body may have absorbed water sitting in the water as well making it appear as only mild. Not sure as I am only a former prosecutor. Have read a lot of autopsies though and investigated causes of injury or death. And resting in water sounds like a tired, thirsty, and or over heated and maybe nauseous runner to me. Maybe rumners should use the buddy principal when running in dangerous or long runs like swimmers divers, etc. Alex

The bit about the stream is a good point. Unless that was something he routinely did on runs, it does strike me as odd and perhaps indicative that he was overheated beyond what even he, an expert desert runner, was used to, and/or dehydrated. I wonder, too, whether immersing one's legs in cold stream water (if it was cold) could create a shock on the body which would stress the heart further, inducing cardiac arrest.
I'm not suggesting that anyone trying this would die; the heart abnormalities may have predisposed him to die under the mixture of dehydration, overheating, and then the rapid cooling.